Clinical Guideline Pain Management

Pain Management

This guidance covers:

WHO Analgesic Ladder Reducing dosing errors with opioids Opioid toxicity General Pain Management ? Acute General Pain Management ? Postoperative (excluding obstetrics) General Pain Management ? Obstetrics (NOT for women in labour) General Pain Management ? Chronic General Pain Management ? Renal Patients Analgesic subcutaneous syringe drivers Co-prescribing with opioids Appendix 1: Dose conversion chart for strong opioids

Clinical Guideline

Pain Persisting or Increasing

+/- Adjuvant: NSAID

WHO Analgesic Ladder The WHO analgesic ladder is a validated system for treating pain.

Step 3. Moderate to Severe Pain Strong Opioid:

Morphine Sulphate, Diamorphine, Fentanyl

+ non opioid

Step 2. Mild to Moderate Pain Weak Opioid:

Codeine, Dihydrocodeine, Tramadol

+ non opioid

Step 1. Mild Pain Non Opioid Analgesia:

Paracetamol

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 1 of 15

Reducing Dosing Errors with Opioids This guidance has been produced in response to a National Patient Safety Agency Rapid Response Report, which was issued due to the increase in number and severity of incidents concerning opioid medicines.

The following must be followed when prescribing, dispensing or administering opioid medicines: Confirm any recent opioid dose, formulation, frequency of administration and any other

analgesic medicines prescribed for the patient. Ensure where a dose increase is intended, that the calculated dose is safe for the patient. Check the usual starting dose, frequency of administration, standard dosing increments,

symptoms of overdose, and common side effects of that medicine and formulation.

Opioid Toxicity If administering strong opiates then naloxone (the antidote) must be available.

Symptoms of opioid toxicity include: respiratory depression, hypotension, circulatory failure, coma, convulsions, rhabdomylosis, renal failure, pinpoint pupils, agitation, vivid dreams, nightmares, hallucinations, confusion and myoclonic jerks.

The specific antidote naloxone is indicated if there is coma or bradypnoea. Since naloxone has a shorter duration of action than many opioids, close monitoring and repeated injections are necessary according to the respiratory rate and depth of coma. When repeated administration of naloxone is required, it can be given by continuous intravenous infusion instead and the rate of infusion adjusted according to vital signs.

Doses of naloxone for opioid overdosage: By intravenous injection, 400micrograms ? 2 mg; if no response repeat at intervals of 2?3 minutes to a maximum of 10 mg, then review diagnosis. Further doses may be required if respiratory function deteriorates By subcutaneous or intramuscular injection, dose as for intravenous injection but use only if intravenous route not feasible (onset of action slower) By continuous intravenous infusion using an infusion pump, 4 mg diluted in 20 mL intravenous infusion solution [unlicensed concentration] at a rate adjusted according to response (initial rate may be set at 60% of initial intravenous injection dose (see above) and infused over 1 hour)

In palliative care and chronic opioid use lower doses should be used to manage opioid-induced respiratory depression and sedation, while maintaining adequate analgesia:

By intravenous injection, 100 ? 200micrograms; given at 2 to 3 minute intervals Additional doses may be necessary at one to two hour intervals depending on the response

of the patient and the dosage and duration of action of the opioid administered.

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 2 of 15

General Pain Management ? Acute

Mild Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily.

Moderate Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily + Codeine 30 to 60mg orally every 4 to 6 hours (Combination product available: Co-codamol 30/500mg One to two tablets, orally, every 4 to 6 hours. Maximum: 8 tablets daily) or Tramadol 50 to 100mg orally every 6 hours (For patients taking regular tramadol: Tramadol MR 100 to 200mg, orally, twice a day) +/NSAID - Ibuprofen 400mg, orally, every 6 to 8 hours

(Diclofenac MR 75mg, orally, twice daily may be considered in patients with cancer)

Severe Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily + Morphine sulphate oral solution 10mg/5mL 5 to 10mg every 4 hours when required If oral route not possible: give 2.5 to 5mg of morphine sulphate injection intramuscularly (IM) every 4 hours or 2.5mg IV hourly when required. (and STOP any weak opioids -- eg, codeine or tramadol) +/NSAID - Ibuprofen 400mg every 6 to 8 hours

General points: When mild analgesics fail, change to a stronger analgesic further up the pain ladder. Do not

change to a drug of similar potency; this will not achieve better pain control. Combinations of analgesics with different mechanisms of action are more effective than single

agents. Continuous pain warrants continuous analgesia, avoid prescriptions for when required

analgesia. Prescribe a regular dose. Intermittent pain warrants intermittent analgesia. Patients should have their pain control regularly assessed. Consider new presentations of pain

eg: neuropathic pain - see Neuropathic Pain Guidelines.

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 3 of 15

General Pain Management -- postoperative (excluding obstetrics)

Mild Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily.

Intravenous paracetamol stat dose can be used in post-operative patients who are unable to swallow, or unable to use or refuse suppositories. Under 50 kg: 15mg/kg by intravenous (IV) infusion over 15 minutes every 4 to 6 hours. Max. 3g daily. Over 50 kg: 1g by IV infusion over 15 minutes every 4 to 6 hours. Max. 4g daily

Moderate Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily. + Codeine 30 to 60mg orally every 4 to 6 hours (Combination product available: Co-codamol 30/500mg One to two tablets, orally, every 4 to 6 hours. Maximum: 8 tablets daily) or Tramadol 50 to 100mg orally every 6 hours (For patients taking regular tramadol: Tramadol MR 100?200mg, orally, twice a day) +/NSAID - Ketoprofen 100mg bd orally/rectally/intramuscularly (inpatients only for upto 3 days, then switch to either diclofenac or ibuprofen if NSAID still required.

Diclofenac 50mg tds orally, 75 to150mg daily in divided doses rectally, Ibuprofen 400mg orally three times a day

NSAIDs may enhance anticoagulant effect of anticoagulants but can be concurrently prescribed with prophylaxis doses of LMWH.

Diclofenac 75mg in 2ml (Dyloject?) IV injection is available for use in THEATRE ONLY for use in anaesthetised patients. Note: IV Diclofenac is contra-indicated in patients receiving concomitant NSAIDs including cyclooxygenase-2 selective inhibitors or anticoagulant use (including low dose heparin). For full prescribing information ? Diclofenac Injection BP 75mg/3ml - Summary of Product Characteristics (SPC) - electronic Medicines Compendium (eMC)

Severe Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily. Or use IV paracetamol (for dosing see under mild pain) + Morphine sulphate oral solution 10mg/5mL 5 to 10mg every 4 hours when required If oral route not possible: give 2.5 to 5mg of morphine sulphate injection intramuscularly (IM) every 4 hours or 2.5mg IV hourly when required. (And STOP any weak opioids -- eg, codeine or tramadol). +/NSAID ? Diclofenac 50mg tds orally, 75-150mg daily in divided doses rectally

Ibuprofen 400mg every 6 to 8 hours

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 4 of 15

Severe -- for patients deemed suitable by the Acute Pain Team or an Anaesthetist

Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily. Or use IV paracetamol (for dosing see under mild pain) + Epidural or Patient Controlled Analgesia (PCA) infusions. Patients on these infusions will be seen regularly and treatment optimised, and step down therapy advised upon by the Acute Pain Team or Anaesthetist

Any queries regarding pain control must be referred back to the Acute Pain Team or Anaesthetist. Always ensure that naloxone is available on the ward.

Standard PCA at WUTH: morphine sulphate 120mg and cyclizine 120mg in 60mL glucose 5%. These are supplied as a controlled drug from the Pharmacy Aseptic Unit and must be prescribed on PCIS. Do not prescribe additional cyclizine for patients receiving a PCA.

Standard epidurals at WUTH: Diamorphine 30mg in bupivacaine 0.1% 500mL (used by surgical division) Bupivacaine 0.1% and Fentanyl 0.0002% in sodium chloride 0.9% 250mL (used in obstetrics)

Epidurals are not prescribed on PCIS within the surgical division but should be prescribed on a preprinted yellow chart. In Womens directorate they are prescribed on a pre-printed epidural prescription chart.

Concomitant Use Of Other Opioids

PCA If a patient has been admitted on regular slow release morphine/ oxycodone tablets/ capsules or regular methadone these should be continued whilst the patient is on the PCA. IV morphine stat doses can also be administered whilst on the PCA. Any breakthrough morphine/ oxycodone liquid should not be continued, nor should IM morphine stat doses be prescribed. Stat doses can be restarted after PCA removal if appropriate. For advice on patient's with fentanyl or buprenorphine patches please contact the Acute Pain team or an Anaesthetist.

Epidurals With epidurals, no regular opiates should be prescribed. However exceptions are sometimes made if there has been input from the Acute Pain team/ Anaesthetist.

If you have any queries regarding any of the above then contact the Acute Pain Team/ Anaesthetists

General points: When mild analgesics fail, change to a stronger analgesic further up the pain ladder. Do not change

to a drug of similar potency; this will not achieve better pain control. Combinations of analgesics with different mechanisms of action are more effective than single

agents. Continuous pain warrants continuous analgesia, avoid prescriptions for when required

analgesia. Prescribe a regular dose. Intermittent pain warrants intermittent analgesia. Patients should have their pain control regularly assessed. Consider new presentations of pain

eg: neuropathic pain - see Neuropathic Pain Guidelines.

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 5 of 15

General Pain Management -- Obstetrics (NOT for women in labour)

Mild/ Moderate Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily.

Intravenous paracetamol can be used in post-operative patients who are unable to swallow, or unable to use or refuse suppositories.

Under 50 kg: 15mg/kg by intravenous (IV) infusion over 15 minutes every 4 to 6 hours. Max. 3g daily.

Over 50 kg: 1g by IV infusion over 15 minutes every 4 to 6 hours. Max. 4g daily. + Codeine 15 to 30mg orally every 4 to 6 hours (Combination products available: Co-codamol 30/500mg One to two tablets, orally, every 4 to 6 hours. Maximum: 8 tablets daily) +/NSAID (for post natal use only)- Diclofenac 50mg tds orally

NSAIDs are contra-indicated in patients receiving concomitant NSAIDs including cyclooxygenase-2 selective inhibitors. The SPC advises that concomitant use of diclofenac and other medication with anticoagulant properties (such as tinzaparin) should be done with caution. Clinical investigations do not appear to indicate that diclofenac sodium has an influence on the effect of anticoagulants and so this practice can be continued.

Severe Paracetamol 1g orally or rectally every 4 to 6 hours. Max 4g daily + Morphine sulphate oral solution 10mg/5mL 5 to 10mg every 4 hours when required If oral route not possible: give 2.5 to 5mg of morphine sulphate injection intramuscularly (IM) every 4 hours or 2.5mg IV hourly when required. (And STOP any weak opioids -- eg, codeine or tramadol). +/-

NSAID (for post natal use only)? Diclofenac 50mg orally three times a day

General points: When mild analgesics fail, change to a stronger analgesic further up the pain ladder. Do not

change to a drug of similar potency; this will not achieve better pain control. Combinations of analgesics with different mechanisms of action are more effective than single

agents. Continuous pain warrants continuous analgesia, avoid prescriptions for when required

analgesia. Prescribe a regular dose. Intermittent pain warrants intermittent analgesia. Patients should have their pain control regularly assessed. Consider new presentations of pain

eg: neuropathic pain - see Neuropathic Pain Guidelines.

For information on the use of pethidine, refer to separate obstetric guidelines ("Management of labour pain relief")

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 6 of 15

General Pain Management - Chronic

If pain assessment indicates opioid sensitive chronic pain, commence a regular strong opioid. First choice Morphine is the strong opioid of choice Note in patients with impaired renal function there is an increased risk of toxic side-effects with the majority of opioids, due to drug and metabolite accumulation. In patients with chronic kidney disease (CKD) stages 3-5 or with creatinine clearance < 30ml/min opioids should be used with caution (see General Pain Management ? Renal Patients on page 10) and specialist advice sought.

Treat as for acute pain then add Morphine sulphate MR capsules (Zomorph?) Initial dose: determine total daily requirements of morphine sulphate oral solution. This dose should be given in two divided doses of Zomorph. Round doses to the nearest 10mg -see example below.

And (for breakthrough pain) Continue morphine sulphate oral solution Give one sixth of the total daily morphine dose every 4 hours when required. Round doses to the nearest 5mg. See example below.

(For patients with problems swallowing solid dose formulations, morphine sulphate modified release capsules can be opened and the contents swallowed without chewing. The capsule contents may also be administered via a PEG tube.)

Dose requirements for oral morphine ? example calculation Patient requires 5mg of morphine sulphate oral solution four times in a 24 hour period.

Therefore:

4 x 5mg = 20mg (Total daily dose of morphine)

20mg ? 2 = 10mg

Therefore commence morphine sulphate modified release capsules/tablets 10mg twelve hourly.

For breakthrough analgesia use one sixth of total daily morphine dose:

20mg ? 6 = 3.33mg

Round to nearest convenient dose and give 4 hourly when required, therefore commence morphine sulphate oral solution 5mg every 4 hours when required.

Further dose adjustments in opioid sensitive pain Adjust regular dose of morphine sulphate modified release capsules/tablets according to the frequency of use of breakthrough analgesia and the patient's general clinical condition. If a patient's pain is uncontrolled, and more frequent breakthrough doses are required then recalculate the regular daily dose of oral morphine.

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 7 of 15

When increasing the regular morphine dose remember to include breakthrough doses in the new total daily dose calculation ? example calculation

A patient is having 10mg of morphine sulphate modified release capsules/tablets twelve hourly. In addition they are prescribed 5mg morphine sulphate oral solution every four hours when required for breakthrough pain, of which they have received four doses in the previous 24 hours. Therefore:

(2 x 10mg) + (4 x 5mg) = 40mg (Total daily dose of morphine)

40mg ? 2 = 20mg

Therefore the new regular dose of morphine sulphate modified release capsules/tablets to be commenced is 20mg twelve hourly

For breakthrough analgesia use one sixth of total daily morphine dose

40mg ? 6 = 6.66mg

Round to nearest convenient dose and give 4 hourly when required, therefore commence morphine sulphate oral solution 5mg every 4 hours when required.

Second choice -- for patients unable to tolerate morphine Consider simple measures such as:

Dose reduction of morphine, Appropriate rehydration Adjuvant medication ? eg, haloperidol 1.5mg, orally, at night for 3 to 4 days for

hallucinations and opioid-related nausea, or increased laxatives

Morphine is also available as a modified-release 24-hourly oral preparation (MXL?) which may aid compliance in some patients.

If these measures fail and the patient remains in pain and symptomatic of opioid side effects refer to the Pain Team or Palliative Care Team via PCIS.

Third choice -- for patients in whom the above measures have not worked Oxycodone MR tablets (OxyContin?) In patients transferring from morphine, halve the total daily dose of morphine to calculate the equivalent total daily dose of oxycodone. This dose should be given in two divided doses of OxyContin?. Round doses to the nearest 10mg. See example below overleaf

And (for breakthough pain) Oxycodone 5mg/5mL liquid (OxyNorm?) Give one sixth of the total daily dose every 4 hours when required. Round doses to the nearest 5mg. See example overleaf.

Pain Management ? Clinical Guidelines, Version2

Principal author: Karen Herbert, Lead Pharmacist, Medicines Management

Approved by Wirral Drug & Therapeutic Committee: July 2010

Review date: July 2013

Page 8 of 15

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